Provider Demographics
NPI:1013377795
Name:NATURE COAST HIGH RISK MEDICAL MANAGEMENT LLC
Entity Type:Organization
Organization Name:NATURE COAST HIGH RISK MEDICAL MANAGEMENT LLC
Other - Org Name:NATURE COAST PROVIDER OUTREACH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:L
Authorized Official - Last Name:SAVAGE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DO
Authorized Official - Phone:352-436-4328
Mailing Address - Street 1:7562 W GULF TO LAKE HWY
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL RIVER
Mailing Address - State:FL
Mailing Address - Zip Code:34429-7840
Mailing Address - Country:US
Mailing Address - Phone:352-436-4328
Mailing Address - Fax:352-260-0960
Practice Address - Street 1:7562 W GULF TO LAKE HWY
Practice Address - Street 2:
Practice Address - City:CRYSTAL RIVER
Practice Address - State:FL
Practice Address - Zip Code:34429-7840
Practice Address - Country:US
Practice Address - Phone:352-436-4328
Practice Address - Fax:352-260-0960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-24
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10486207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS10486OtherSTATE MEDICAL LICENSE